Cost-effectiveness of guideline-based care for diabetes-related foot ulcers: using discrete event simulation in economic evaluation

BackgroundImplementation of guideline-based care for diabetes-related foot ulcers (DFU) in clinical practice is typically sub-optimal. We aimed to evaluate the cost-effectiveness of implementing different incremental increases in guideline-based care scenarios, compared with current practice, using discrete event simulation models.MethodsThe costs and effectiveness of current practice (identified as 30% receiving guideline-based care, remainder (70%) non-guideline-based care) were compared with seven hypothetical scenarios of implementing incremental increases in guideline-based care (40%, 50%, 60%, 70%, 80%, 90%, 100%) and evaluated using discrete event simulation models, including important events of disease history and parameterised by a large DFU cohort. Incremental cost-effectiveness ratio for each scenario was calculated and compared to willingness-to-pay of AUD28,000 per quality-adjusted life-years (QALY). Probability sensitivity analysis was conducted to incorporate parameter uncertainty by 2,000 random simulations.ResultsUnder a three-year time-horizon, the seven scenarios (40%-100% guideline-based care) were estimated to incrementally save $901-$1843 (AUD 2020) and provide 0.017-0.056 more QALY per person, with all scenarios being cost-saving & more effective than current practice (30% guideline-based care). From probability sensitivity analyses we were increasingly confident (69.7%-89.8% confident) that implementing increased incremental scenarios (40%-100% guideline-based care) would be cost-effective compared with current practice (59.8%-73.4% confident).ConclusionsAll scenarios incrementally increasing guideline-based care were evaluated to be cost-saving and more effective than current practice according to this discrete event simulation modelling based on a large real-world cohort.Key messagesOur findings support the cost-effectiveness of implementing any incremental increase in guideline-based care compared to current practice